Crisis Management

Crisis-Counselor Perceptions of Job Training, Stress, and Satisfaction During Disaster Recovery

Nikki D. Bellamy United States Department of Health and Human Services,

Substance Abuse and Mental Health Services Administration, Rockville, Maryland

Min Qi Wang University of Maryland

Lori A. McGee ICF International, Fairfax, Virginia

Julie S. Liu and Maryann E. Robinson United States Department of Health and Human Services,

Substance Abuse and Mental Health Services Administration, Rockville, Maryland

Objective: The United States Crisis Counseling Assistance and Training Program (CCP; authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 1974/2013) aims to provide disaster- recovery support to communities following natural or human-caused disasters through outreach. Job satis- faction among the crisis counselors the CCP employs may affect the delivery of outreach services to survivors and their communities. The present study was conducted to gain insight into CCP crisis counselors’ experiences with job training and work-related stress as predictors of job satisfaction. Method: Data was collected from 47 CCP service-provider agencies, including 532 completed service-provider feedback surveys to examine the usefulness of the CCP training they had received, the support and supervision provided by program management, the workload and its duration, resources provided, and the stress experienced. Quan- titative and qualitative data were examined, and a multiple linear regression was calculated to predict job satisfaction based on training usefulness, job stress, gender, age, race, full- or part-time status, highest level of education achieved, and supervisory position. Results: The overall regression equation was significant, F(8, 341) � 8.428, p � .000. The regression coefficients indicated that the higher the job training was rated as useful (p � .001), the lower the job stress (p � .01), and the older the age of the respondents (p � .05), the greater the level of job satisfaction. Conclusion: Findings suggest that proper training and management of stress among crisis counselors are necessary for influencing levels of staff job satisfaction. Where self-care and stress management were not adequately emphasized, more stress was reported.

Clinical Impact Statement Crisis counselors work with survivors who have experienced loss and trauma from the devastating effects of a disaster. While working in the community, counselors help people understand their current situation and reactions. They mitigate stress, explore recovery options, promote coping strategies, offer emotional support, encourage contact with others, and facilitate resource connec- tions. To maximize job performance, it is important that counselors receive appropriate training and participate in self-care activities to reduce burnout. We found that the higher counselors rated a training as useful and the lower they reported stress, the higher their rates of job satisfaction.

Keywords: natural disaster, crisis counselor, job training, job stress, job satisfaction

This article was published Online First May 3, 2018. Nikki D. Bellamy, United States Department of Health and Human Services,

Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; Min Qi Wang, School of Public Health, University of Maryland; Lori A. McGee, ICF International, Fairfax, Virginia; Julie S. Liu and Maryann E. Robinson, United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Rockville, Maryland.

The views expressed herein represent the opinions and analyses of the individual authors and may not necessarily reflect the opinions, official policy, or position of the United States Department of Health and Human Services (DHHS), the DHHS Substance Abuse and Mental Health Services Administration (SAMHSA), the SAMHSA Center for Mental Health Ser- vices, the United States Public Health Service, or the United States De- partment of Homeland Security, Federal Emergency Management Agency.

The authors completed this article in their private capacity while working at their respective institutions and extend thanks to all of the grant pro- grams and crisis-counseling staff who contributed to the data-collection effort. Melissa Riley and Alyssa Andrade provided support for data col- lection and analysis through the DHHS SAMHSA Disaster Technical Assistance Center (DTAC), Contract 283122301T, awarded to IQ Solu- tions, Inc. Min Qi Wang and Lori McGee provided support for data effort in the previous DTAC contract, 28342002T, awarded to ICF International. Robert Burgard provided editing assistance.

Correspondence concerning this article should be addressed to Nikki D. Bellamy, United States Department of Health and Human Services, Sub- stance Abuse and Mental Health Services Administration, Center for Mental Health Services, 5600 Fishers Lane, 14E05D, Rockville, MD 20857. E-mail: [email protected]

Psychological Trauma: Theory, Research, Practice, and Policy In the public domain 2019, Vol. 11, No. 1, 19–27 http://dx.doi.org/10.1037/tra0000338

19

The United States Crisis Counseling Assistance and Training Program (CCP) is a federal government program authorized by the Robert T. Stafford Disaster Relief and Emergency Assistance Act (1974/2013) to assist in the recovery of survivors from the psy- chological and behavioral effects of severe disasters through community-based outreach. The CCP employs behavioral health professionals and paraprofessionals recruited as crisis counselors to implement these psychoeducational services. Compromised be- havioral health embodies a range of difficulties, including mental illness, substance misuse and abuse, suicide, and severe psycho- logical distress. As such, interventionists seek to promote positive choices and actions that affect mental and emotional wellness (Robinson, 2016). Crisis counselors tend to be from the same local area as their clients, and they may also have been impacted by the disaster. Their shared trauma sometimes influences the work ex- periences of such counselors (Saakvitne, 2002; Tosone, Nuttman- Shwartz, & Stephens, 2012). Crisis counselors’ job training and work-related stress during disaster recovery may have a significant effect on their job satisfaction. It can be personal, and can ulti- mately affect job performance in the delivery of outreach services to survivors and their communities. The present study was con- ducted to gain insight into CCP crisis counselors’ experiences with training, work-related stress, and how these areas relate to job satisfaction.

Program Structure

Following a presidential disaster declaration that includes indi- vidual assistance, a state, territory, or federally recognized tribe can apply for a CCP grant. The CCP offers two grant programs: the Immediate Services Program (ISP), which runs for 60 days and is intended to provide support in the acute postdisaster phase, and the Regular Services Program (RSP), in which grants last for up to 9 months through the 1-year anniversary of the disaster. When a state, territory, or tribe has received an ISP or RSP grant, they may then hire crisis-counseling staff directly or subcontract with local provider organizations to deliver program services to survivors within affected communities (Norris, Hamblen, & Rosen, 2009).

Crisis counseling is based on key elements of promoting a sense of safety, calm, self- and community efficacy, connectedness, and hope (Hobfoll et al., 2007). Services assume that most survivors are naturally resilient. Crisis counselors are taught that crisis counseling within the context of a CCP differs from traditional psychotherapy in many ways (Norris & Bellamy, 2009). The CCP is essentially a preventive approach with evidence-based practices and is typically not designed to deliver clinical treatment. Services are provided where survivors live, work, worship, or take part in recreational and social activities (Norris & Bellamy, 2009). En- counters are usually brief, rarely over 30 min, and involve more than one or two visits to address short-term needs. CCPs are also encouraged to identify survivors who experience serious distress and clinically diagnosable disorders and connect them to behav- ioral health professionals (Norris & Bellamy, 2009). Most survi- vors reestablish psychological well-being after a disaster by dis- playing resilience, positive coping, and adaptation to adverse events, but some survivors experience posttraumatic stress disor- der (PTSD), distress, depression, anxiety, or other psychiatric disorders (Neria & Shultz, 2012; North & Pfefferbaum, 2013; Uekawa, Higgins, Golenbock, Mack, & Bellamy, 2016).

Crisis-Counselor Training

The training of crisis counselors is a major requirement of a CCP grant because often, crisis counselors are hired paraprofes- sionals who may not have experience in providing disaster-related behavioral health services. These paraprofessionals tend to have backgrounds as retired teachers, social workers, nurses, counsel- ors, first responders (e.g., law-enforcement agents or firefighters), or may be college or graduate students studying in health-related fields. Typically, they are unlicensed persons, but have a demon- strated communication skillset that includes the ability to engage others, establish rapport, be calming and reflective, and validate feelings. Similar to licensed professionals, the paraprofessionals are able to express empathy by paraphrasing, normalizing reac- tions, and displaying active listening skills, or nonverbal attending skills. Licensed clinical or counseling professionals may also be engaged, but they must be willing to understand the difference between their normal psychotherapeutic work and the work of disaster-outreach psychoeducational activities. Many licensed pro- fessionals involved in the CCP take on the role of crisis counselor, team leader, supervisor, or clinical consultant for program referrals for those in need of intensive mental health services or substance- abuse treatment. Crisis counselors tend to have intricate ties to the community, knowledge of cultural and geographical nuances, and interpersonal assets (e.g., are bilingual; have histories of working with children, youth, older adults, or other vulnerable populations).

Required CCP Training

There are six required training courses for crisis counselors that inform program philosophy, goals, and techniques to promote survivor behavioral health and to manage their own stress. These required trainings are delivered in chronological order with content based on the phases of disaster recovery (except for CCP data training which is delivered in the beginning and is ongoing; Zunin, 2000). Training contents are available online from the United States Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA) for anytime public access (see https://www.samhsa.gov/dtac/ccp-toolkit/ train-your-ccp-staff). CCP data-collection guidance and interactive webinar data trainings are supported by SAMHSA’s Disaster Tech- nical Assistance Center (DTAC), also available online (https://www .samhsa.gov/dtac/ccp-toolkit/evaluate-your-ccp) to assist staff with the use of data forms, online, and mobile application collection technologies.

Skills-Based Supplemental Training

Several skills-based trainings have been incorporated by CCP grants. During the immediate aftermath, Psychological First Aid (PFA), has been used to assist people in reducing initial distress, building resiliency, and to foster short-term adaptive functioning (Jacobs, Gray, Erickson, Gonzalez, & Quevillon, 2016). The sup- port of federal funding allowed for the creation of a variety of PFA models sharing this common aim (Brymer et al., 2006; Everly, Jr., McCabe, Semon, Thompson, & Links, 2014; McCabe et al., 2014; Vernberg & Hambrick, 2013; Vernberg et al., 2008). With the financial support of SAMHSA, the National Child Traumatic Stress Network (NCTSN), along with the United States Depart-

20 BELLAMY, WANG, MCGEE, LIU, AND ROBINSON

ment of Veterans Affairs, National Center for PTSD (NCPTSD) developed a PFA model that has been used in CCPs during pre-award grant periods (see http://www.ptsd.va.gov/professional/ continuing_ed/psych_firstaid_training.asp).

To address crisis-counselor skills in the intermediate response and longer-term recovery efforts, the NCTSN and NCPTSD developed the Skills for Psychological Recovery Program (SPR; http://www.ptsd .va.gov/professional/materials/manuals/skills_psych_recovery_manual .asp), again with funding support from SAMHSA (Berkowitz et al., 2010). SPR is designed to foster adaptive coping in disaster survivors who exhibit moderate levels of distress by offering simplified, brief applications of skills commonly related to improved postdisaster recovery. Skills include problem solving, positive activity scheduling, managing reactions, helpful thinking, and building healthy social connections (Berkowitz et al., 2010). SPR is intended to help survi- vors identify their most pressing current needs and concerns, and then offer skills to address those needs. Each skill can be covered in one helping contact, and then reinforced in continuing contacts to include assignments to practice the skills learned (Berkowitz et al., 2010).

CCPs have developed and used child-, youth-, and family- focused curricula such as the Healing After Trauma Skills (HATS; Schonfeld & Gurwitch, 2009). In response to Hurricane Sandy, the Mental Health Association in New Jersey adopted the Family Going On After Loss (GOALs) intervention. (For more informa- tion regarding the intervention, see http://www.mhanj.org/new- jersey-hope-and-healing/ by Maureen Underwood, Joan Milani, and Nicci Spinazzola, and edited by Jennifer Lezak Miller, Renee Burawski, (Underwood, Milani, & Spinazzola, 2004)). Supported by the New Jersey Department of Human Services, Division of Mental Health, GOALS is a structured curriculum with a firm theoretical grounding in disaster mental health, grief theory, family-systems theory, and resiliency, designed to provide a series of psychoeducational support groups for families experiencing a traumatic event.

Training on such topics as suicide prevention, compassion fa- tigue, and self-care have also been incorporated into CCPs. Suicide prevention incorporates a review of SAMHSA-related resources (see https://www.samhsa.gov/suicide-prevention) and skills-based Applied Suicide Intervention Skills Training (ASIST), or Ques- tion, Persuade, and Refer (QPR) Training (Smith, Silva, Coving- ton, & Joiner Jr., 2014).

Job Stress and Stress Management

Crisis counselors may vicariously share the trauma and vulner- ability that disaster survivors experience (Quitangon & Evces, 2015). Repeatedly seeing the devastation that the disaster has caused, as well as listening to survivors’ sad and often heart- wrenching disaster experiences can take a toll on crisis counselors, not only physically, but psychologically (Naturale, 2015). Many in the disaster-response and -recovery field struggle with how to actually implement stress management and self-care techniques (United States Department of Health and Human Services, Sub- stance Abuse and Mental Health Services Administration, 2016).

Several studies have explored disaster-recovery worker stress, self- care, and job satisfaction. Johnstone (2007) explored the issue from personal experience combined with a theoretical perspective of group support using PFA during Hurricane Katrina relief work (Johnstone, 2007). It was found that group support was useful in making it

possible to deal with extraordinary disaster events, as well as promot- ing relief and constructive coping for both survivors and professionals (Johnstone, 2007). Naturale (2009) conducted a secondary data anal- ysis examining posttraumatic and secondary traumatic stress in a group of Manhattan social workers, some of whom participated in the 9/11 response (Naturale, 2009). She found no significant associations between posttraumatic or secondary traumatic stress and the indepen- dent variables of witnessing the disaster, personal loss, education, work experience, disaster-specific training, or supervision (Naturale, 2009). Her findings did indicate that supports such as marriage and economic resources may mitigate distress (Naturale, 2009).

The Louisiana Spirit Specialized Crisis Counseling Services (SCCS) program examined counselor perceptions of training and SCCS (Hansel et al., 2011). Results from this study showed that provider perceptions of personal strengths (i.e., hurricane-related experiences and their aftermath helped them substantially to pro- vide SCCS), derived from Hurricanes Katrina and Rita, were associated with high levels of program satisfaction. Conversely, difficulties in providing SCCS were associated with lower levels of program satisfaction. Multiple regression analyses reported that provider’s perceived negative impact of the hurricane on survivors predicted increased perceived helpfulness of SCCS-provider train- ing and subsequent services to survivors (Hansel et al., 2011). Qualitative findings from a mixed-methods pilot-evaluation study of a psychoeducational intervention conducted with community health workers participating in Hurricane Sandy recovery indi- cated that the respondents valued learning about common stress responses and incorporating coping as part of a daily routine. Team building and normalization of emotions were seen as ancillary benefits that would reduce stress levels in the workplace (Powell & Yuma-Guerrero, 2016).

Supervisors play a key role in promoting supervisee self-care postdisaster (Aten, Madson, Rice, & Chamberlain, 2008). This study reported on effective supervisee self-care strategies for su- pervisors based on disaster-related mental health research, super- vision research of psychology training programs, and lessons learned from Hurricane Katrina in South Mississippi to include (a) establishing emergency protocol, (b) modeling self-care, acknowl- edging disaster experiences while maintaining boundaries, (c) pro- viding education and training, (d) facilitating development of and monitoring self-care plans, and (e) watching for personal problems to intervene as necessary (Aten et al., 2008). In the present study, we hypothesized that crisis counselors who reported higher rates of training usefulness and lower rates of job-related stress would indicate higher levels of job satisfaction. Factors such as gender, age, race, supervisory status, highest level of education, and hours worked per week were also considered.

Method

Study Sample

Forty-seven service-provider agencies receiving CCP grant funding across seven states that participated in the Service Pro- vider Feedback Survey (SPFS), a copy of the SPFS is available online (https://www.samhsa.gov/dtac/ccp-toolkit/ccp-data-forms- trainings), were included in the mixed-method study and were eligible for analysis (SAMHSA, 2015). The SPFS was voluntary and usually administered twice during an RSP grant period. Data

21DISASTER-CRISIS-COUNSELOR JOB FEEDBACK

were collected on surveys submitted to SAMHSA DTAC from November 2012 through March 2016. A total of 532 surveys comprised the study sample. Table 1 shows the CCP grants and the number of SPFS responses by type of natural disaster. The major- ity of SPFS surveys were from crisis-counseling staff who had participated in CCP grants in response to hurricanes, with the largest number from the New York grant in response to Hurricane Sandy, which made land fall in October 2012.

Instrument

The SPFS is a United States Office of Management and Budget- approved form (No. 0930–0270) used to yield a standardized assessment of team leaders (i.e., supervisors) and crisis counselors’ opinions and reactions to their CCP work. Sections of the form ask users to evaluate the usefulness of the trainings they received, the support, supervision, and opportunities for growth provided by the work, the appropriateness of the workload, the adequacy of re- sources and tools available, and for an evaluation of provided services. Another section is composed of five questions about stress, which examine whether an individual’s work, or the reac- tion to it, has caused problems in other areas of his or her life (Norris et al., 2009). The present study’s stress-scale reliability yielded � � .88, which is comparable to the � � .85 reported in Norris et al. (2009). The final questions ask about job factors such as work hours, duration, whether or not the respondent is in a supervisory role, education, and basic demographic questions.

Question items. Twenty-three items rated on a 5-point Likert scale from lowest (1) to highest (5) represented the study variables for job-training usefulness, job stress, and job satisfaction (see Tables 3, 4, and 5). A subscale for each of these areas was created as an outcome variable. Training Usefulness was scored by sum- ming seven items related to each of the trainings (i.e., core content, transition from the ISP grant period to the RSP grant period, mid-program, disaster anniversary, phasedown, evaluation tools, and others). The minimum score was 0 (did not complete training) and the maximum score was 35 (extremely useful; M � 16.96,

SD � 7.10). Job satisfaction was scored by summing 11 items addressing quality of supervision, appropriateness of workload, and likelihood of recommending the project. The minimum score was 11 (extremely poor) and the maximum score was 55 (excel- lent; M � 44.21, SD � 7.59). The level of job stress was scored by summing five items comprising reactions or situations related to crisis-counseling work. The minimum score was 5 (not at all) and the maximum score 25 (very much; M � 7.57, SD � 3.48).

The final questions of the survey were for gender, age, ethnicity, race, number of hours worked in a typical week, supervisory status of other crisis counselors, and highest level of education achieved. For the purpose of analysis, several variables were recoded. Age was recoded into three categories, 18 to 39, 40 to 64, and 65 and older. Number of hours worked per week was recoded into a dichotomous variable, part-time (�40 hr/week) or full-time (�40 hr/week) categories. Eight options for respondents to select regarding highest level of education were recoded into three cat- egories: 1 (GED/high school), 2 (some college, associate’s, or bachelor’s degree), and 3 (graduate or professional degree). Racial identity for those respondents who checked any variation of more than one race was recoded as multiracial. The last item provided a space to share any other comments through an open-ended re- sponse.

Survey administration. The SPFS survey is customarily con- ducted twice, approximately 6 and 12 months postdisaster using a web-based format to for respondents to complete anonymously. Data from the two survey administrations were combined for these study analyses. Team leaders and counselors were eligible for the survey if they had been working in the program for at least a month, regardless of part- or full-time status, and usually given a 2-week time frame to complete.

Table 1 Service Provider Feedback Survey Respondents by Type of Disaster Grant

CCP grant declaration Surveys (N � 532)

Hurricane n (%) LA-4080 65 (12.2) NJ-4086 68 (12.8) NY-4085 295 (55.5)

Flooding CO-4145 37 (7.0) WA-4168 2 (0.4)

Tornado OK-4117 22 (4.1) TX-4223 32 (6.0)

Wildfire CO-4134 11 (2.1)

Note. CCP � Crisis Counseling Assistance and Training Program; LA � Louisiana; NJ � New Jersey; NY � New York; CO � Colorado; OK � Oklahoma; TX � Texas; and WA � Washington. The four digit number that follows the state acronym is the Federal Emergency Management Agency presidential disaster declaration number.

Table 2 Characteristics of Service-Provider Staff

Supervisor (n � 100)

Nonsupervisor (n � 390)

Characteristics n (%) n (%)

Gender Female 73 (14.9) 293 (59.8) Male 27 (5.5) 97 (19.8)

Age 18–39 35 (8.6) 179 (44.0) 40–64 44 (10.8) 128 (31.4) �65 6 (1.5) 15 (3.7)

Race Asian/Pacific Islander 5 (1.1) 26 (5.8) American Indian/Alaska Native 3 (.7) 2 (.4) Black/African American 21 (4.7) 100 (22.5) White/Caucasian 64 (14.4) 213 (47.9) Multiracial 1 (.2) 10 (2.2)

Hours Worked Per Week Part-time (�40) 48 (9.9) 148 (30.6) Full-time (�40) 51 (10.6) 236 (48.9)

Highest level of education���

High school/GED 3 (.6) 16 (3.4) Some college/associate’s or

bachelor’s degree 23 (4.9) 228 (48.4) Graduate/professional degree 68 (14.4) 133 (28.2)

Note. Chi-square test. ��� p � .001.

22 BELLAMY, WANG, MCGEE, LIU, AND ROBINSON

Statistical analysis. For descriptive statistics, we used fre- quencies, percentages, means, and a nonparametric statistic for cross-tabulations on demographic variables. Multiple regression has been conducted in a number of disaster-experience studies to examine predictability among factors (Galea, Tracy, Norris, & Coffey, 2008; Hansel et al., 2011; Powell & Yuma-Guerrero, 2016; Reifels, Naccarella, Blashki, & Pirkis, 2014; C. Tosone, McTighe, & Bauwens, 2015). We used it in this study to predict the dependent variable, job satisfaction, based on two job-related indicators and demographic characteristics. The model analysis would determine not only how much of the variation in job satisfaction could be explained by training usefulness, job stress, gender, age, race, full- or part-time status, highest level of educa- tion achieved, and supervisory position, but also the relative con- tribution of each of these predictors in explaining the variance. All assumptions (i.e., normality, little multicollinearity or autocorre- lation, and homoscedasticity) for the regression were met. Content analysis was conducted on qualitative responses to the open-ended question.

Results

Most of the 532 survey participants were women (74.6%) and from age 23 to 82 years (M � 41, SD � 13.25). Of the total sample, 306 (63.2%) persons racially identified themselves as White or Caucasian, 130 (26.9%) as Black or African American, and 80 (15%) identified themselves as Hispanic or Latino. One hundred (20.4%) respondents reported supervising the work of

crisis counselors. Some college, associate’s or bachelor’s degree was reported by 272 (53.1%) people, and graduate or professional degree by 219 (42.8%) respondents as the highest level of educa- tion attained. Slightly over half (n � 308, 58.8%) worked full-time at �40 hr/week, and 216 (41.2%) worked �40 hr/week. The number of months that respondents reported working with the CCP (n � 509) ranged from 1 to 24 months (M � 7.12, SD � 2.65).

Demographics and Work-Related Factors

Table 2 shows demographic and key job factors of survey respondents based on supervisory status. No statistically signifi- cant differences were found between supervisory status and what was expected for gender, age, race, and hr/week (part- or full-time) categorical variables. The �2 goodness-of fit test was significant for differences between supervisory status and expected highest level of education achieved, �2(2, 471) � 42.731, p � .001. Of those who supervised the work of crisis counselors, 72% had as their highest level of education graduate or professional degrees, as opposed to 35% of crisis counselors with these degrees.

Job-Training Usefulness

Table 3 presents descriptive statistics for the seven items rating job-training usefulness on the SPFS. As can been seen in Table 3, over 60% of the crisis counselors reported the core content, CCP evaluation tools, and other trainings (e.g., self-care, PFA, SPR) as either very useful or extremely useful. Alternatively, less than 10%

Table 3 Descriptive Statistics for Provider Survey Job-Training Items

Provider survey items M (SD) Not at all useful Slightly useful Moderately useful Very useful Extremely useful

Core content 3.63 (1.48) 3 (.6%) 24 (4.5%) 104 (19.6) 172 (32.5%) 175 (33%) Transition to RSP 3.41 (1.57) 15 (2.8%) 27 (5.1%) 108 (20.3%) 173 (32.5%) 146 (27.4%) Midprogram 1.75 (2.06) 4 (.8%) 10 (1.9%) 52 (9.8%) 93 (17.5%) 76 (14.3%) Disaster anniversary .42 (1.26) 1 (.2%) 3 (.6%) 10 (1.9%) 23 (4.3%) 19 (3.6%) Phasedown .769 (1.62) 1 (.2%) 1 (.2%) 22 (4.1%) 45 (8.5%) 32 (6.0%) CCP evaluation tools 3.55 (1.54) 10 (1.9%) 12 (2.3%) 106 (19.9%) 177 (33.4%) 165 (31.1%) Other training (e.g. self-care, skills for

psychological recovery) 3.43 (1.77) 3 (.6%) 13 (2.4%) 72 (13.5%) 167 (31.4%) 183 (34.4%)

Note. RSP � Regular Services Program; CCP � Crisis Counseling Assistance and Training Program. Range of n for each of the training items was 530–532. Missing data (i.e., did not provide a response to question item) based on total number of surveys (N � 532) for each of the training items were as follows: core content (n � 52, 9.8%), transition to RSP (n � 63, 11.8%), midprogram (n � 297, 55.8%), anniversary (n � 476, 89.5%), RSP phasedown (n � 431, 81%), CCP data (n � 60, 11.3%), and other (n � 94, 17.7%).

Table 4 Descriptive Statistics for Provider Survey Job-Stress Items

Provider survey items M (SD) Not at all A little bit Somewhat Quite a bit Very much

Difficulty handling other stressful events or situations due to crisis- counseling work 1.53 (.85) 341 (64.5%) 118 (22.3%) 51 (9.6%) 13 (2.5%) 6 (1.1%)

Work or your reaction to it interfered with how well you take care of your physical health 1.64 (.95) 324 (61.5%) 106 (20.1%) 66 (12.5%) 25 (4.7%) 6 (1.1%)

Work or your reaction to it interfered with ability to work or carry out other daily activities 1.51 (.84) 353 (66.9%) 105 (19.9%) 50 (9.5%) 16 (3%) 4 (.8%)

Work or your reaction to it affected your relationships with your family or friends, social, recreational or community activities 1.46 (.79) 365 (69%) 104 (19.7%) 46 (8.7%) 9 (1.7%) 5 (.9%)

Been distressed or bothered about your reactions? 1.43 (.76) 365 (70%) 107 (20.3%) 40 (7.6%) 6 (1.1%) 5 (.9%)

Note. Range of n for each of the items was 527–529.

23DISASTER-CRISIS-COUNSELOR JOB FEEDBACK

of the crisis counselors indicated disaster-anniversary and phasedown-training as very or extremely useful. The mean values also reflected this sentiment (i.e., not at all useful) for these two trainings. Many comments to the open-ended question were about the training and were very positive. Specifically, several crisis counselors mentioned that SPR should have been conducted earlier in the program or as a part of the core-content training. Counselors also stated several times that it would be helpful if the data forms could be completed on an electronic device such as a smartphone or tablet, as opposed to filling out a hard copy. Over 80% of crisis counselors did not provide responses for the disaster-anniversary or phasedown-trainings items.

Job Stress

According to Table 4, the vast majority of crisis counselors, over 80%, reported a little bit to not at all on the job-stress items. The stress-item means reflected this same value rating. Seventy percent of crisis counselors indicated that they were not at all distressed or bothered about their reactions. The item that received about 12% with a somewhat stressed response related to whether “the crisis-counseling work or your reaction to it interfered with how well you take care of your physical health.” Comments to the open-ended question related to reducing job stress included the support of coworkers, team leads, and/or supervisors through encouragement of self-care, information sharing, and guidance.

Job Satisfaction

Crisis counselors reported the top three highest rated items on the job-satisfaction subscale to be excellent: (a) opportunities to interact with other staff in supportive ways (46%), (b) understand- ing how [one’s] job fits into the bigger picture of a community’s disaster response (42.3%), and (c) the likelihood of recommending this project to a friend or family member if needed (46.1%; see Table 5). The lowest reported mean from fair to good was for adequacy of the resources and tools available to do the job (M � 3.66, SD � .99). Over 80% of the crisis counselors reported that overall quality of project services was either good (51.1%) or

excellent (33.8%). Comments to the open ended question related to job satisfaction included such statements as the following. “Over- all, working on this project has been a very positive experience. I have had the privilege to work with compassionate, intelligent, creative individuals every day.” “The team I work with has been extraordinary . . . just the ideas on how and where to outreach in the first few months was ‘think tank’ like I never saw . . . and even better . . . was followed with action.” “This is a very rewarding job knowing I have made a difference in someone’s life and have enabled them to move forward.” And “The program is amazing but sometimes we are limited on resources that can be provided to the individual we are working with.”

Job Training, Stress, and Satisfaction

A multiple linear regression was calculated to predict job satis- faction based on training usefulness, job stress, gender, age, race, full- or part-time status, highest level of education achieved, and supervisory position. Only 350 surveys out of the total 532 (65.78%) were included in the multiple regression analysis. For this analysis, race was recoded into a binary variable and catego- rized as White and Non-White. Results of the overall regression equation were significant, F(8, 341) � 8.428, p � .000, and the model accounted for 16% of the variance in job satisfaction. Results show that the study hypothesis was supported. The regres- sion coefficients indicated that the higher the job training was rated as useful (p � .001), the lower the job stress (p � .01), and the older the age of the respondents (p � .05), the greater the level of job satisfaction (see Table 6).

Qualitative Data

A total of 140 (approximately 26%) respondents wrote in the open comment space of their survey. The qualitative responses often described stressful experiences and issues with support and supervision. The experiences depended on several factors, includ- ing supervision, stress management, program management, train- ing, organizational communication, and resource availability. Some of these areas were among those the respondents rated the

Table 5 Descriptive Statistics for Provider Survey Job-Satisfaction Items

Provider survey items M (SD) Extremely poor Poor Fair Good Excellent

Quality of supervision 4.08 (.96) 12 (2.3%) 23 (4.3%) 87 (16.4%) 199 (37.4%) 209 (39.4%) Opportunities to interact with other staff in supportive ways 4.27 (.80) 4 (.8%) 9 (1.7%) 68 (12.9%) 204 (38.3%) 243 (46%) Support and training provided to help avoid compassion fatigue or

stress of listening to and helping others 4.00 (.96) 12 (2.3%) 20 (3.8%) 109 (20.5%) 197 (37.6%) 186 (35.5%) Opportunities for professional and personal growth 3.88 (1.02) 13 (2.5%) 38 (7.3%) 116 (22.2%) 190 (36.3%) 166 (31.7%) Appropriateness of the workload 3.93 (.88) 9 (1.7%) 21 (4%) 112 (21.2%) 244 (46.2%) 142 (26.9%) Adequacy of the resources and tools available to do your job 3.66 (.99) 15 (2.8%) 46 (8.7%) 152 (28.8%) 206 (38.7%) 108 (20.5%) Understood how your job fits into the bigger picture of a

community’s disaster response 4.26 (.77) 4 (.8%) 10 (1.9%) 54 (10.2%) 236 (44.8%) 223 (42.3%) Data from the evaluation were shared with crisis-counseling teams

and used to inform work 3.79 (.97) 13 (2.5%) 43 (8.3%) 108 (20.7%) 236 (45.3%) 121 (23.2%) Believe types of services provided by the project matched

community needs 3.87 (.91) 10 (1.9%) 31 (5.9%) 105 (20%) 249 (47.3%) 131 (24.9%) Overall quality of project services 4.16 (.75) 4 (.8%) 8 (1.5%) 67 (12.7%) 269 (51.1%) 178 (33.8%) Likely to recommend this project to a friend or family member if

needed 4.25 (.85) 7 (1.3%) 10 (1.9%) 68 (13%) 197 (37.7%) 241 (46.1%)

Note. Range of n for each of the items was 521–530.

24 BELLAMY, WANG, MCGEE, LIU, AND ROBINSON

lowest. Specifically, resources, use of data from evaluations, ser- vices matched to need, personal growth, and workload were rated below 4 (good). However, since few respondents provided com- ments, examples for improvement were compared with the results of the quantitative analysis to find commonalities.

Training. Some of the comments requested additional data- collection training and further guidance on definition of variable items on the forms. Some wanted training on how to address instances when community resources are low or deadlines have passed for state and federal grants and other kinds of disaster-relief funding. Respondents reported reluctance to make referrals for limited or delayed resources when urgent needs were expressed.

Stress management. Some felt that greater emphasis should be placed on stress management at the beginning of the program, but that additional opportunities for developing these techniques were available throughout the program. SPR was mentioned as an important training to gain what crisis counselors felt were the necessary skills to engage survivors and address their mental health needs. Respondents desired more opportunities for personal growth and professional development than provider sites offered. This is consistent with the relatively low rating of personal growth in the quantitative data. In addition, assigning all outreach activi- ties of a certain type (e.g., canvassing vs. public presentations) to one group of staff members led to burnout and anger among some staff.

Communication. Overall the crisis counselors felt that com- munication at all levels could be improved. Crisis counselors commented that team leaders were often hard to reach, which caused them to feel unable to get the help and support they needed when issues arose. Some staff complained that their provider agencies lacked direction and organization. The counselors some- times felt that their daily activities were not assigned well or at all, which led them to coordinate outreach efforts themselves, leaving them less time to perform actual outreach activities.

Resources. A major challenge that crisis counselors identified in the open comments was the lack of behavioral health or afford- able housing resources, both for themselves and the survivors in the communities, which were lacking even before the disaster. Many felt that they needed more assets, especially postdisaster, to do their jobs adequately. Counselors were also frustrated with the lack of referral entities that they were able to make to those they served. Informational materials could have been shared in the form of accurate data about affected areas to support more effective canvassing, or more training in the early phase of the program.

Discussion

The regression analysis supported the study hypothesis that, taking into account the age of the counselor, the more useful the job training was rated and the lower the level of reported job stress, the greater the level of job satisfaction. Counselors who partici- pated in the CCP training modules found them to be very or extremely useful when they conducted outreach in their commu- nities. The current CCP data training includes a mix of video vignettes, slide presentations, and learning-test checks that were rated extremely useful for understanding data forms and data-entry systems. Disaster-anniversary training can be improved by creat- ing a resource toolkit, as crisis counselors would benefit from knowing what other types of events or activities CCPs have conducted to recognize an anniversary in working with their com- munities. Recommendations to improve the training format in- clude web-based delivery, incorporation of real-world scenarios, active learning exercises, and multimedia. All training can include skill building, data usage, and self-care content, and reducing the number of trainings may foster cost savings for the program.

Even though supervisory status was not a statistically significant variable in the regression equation for job satisfaction, respondents indicated that support and supervision from providers in the pro- gram was good. Other variables in the regression equation that were not statistically significant included whether or not a person was White or Non-White, had a full- or part-time work schedule, and highest level of reported academic education. Crisis counsel- ing is outreach work and occurs in community settings during times when survivors are more likely to be at home or available. As a result, having flexible work schedules with varying hours per week, along with start and ending times (i.e., often evening and weekend hours are necessary) and varying assignments may be beneficial in attracting staff across different demographic, work- experience, and education profiles. The result that the highest level of education was not statistically significant may be explained by the variety of trainings offered throughout the CCP grant cycle to enhance and practice interaction and referral skills.

Although crisis counselors were working in postdisaster envi- ronments, which can involve multiple stressors and challenges, they reported relatively low levels of job stress. The lower than expected levels of stress may be attributed to respondent age, which may be the result of older adults having more experience with adverse events, thus being able to “bounce back” and posi- tively recover. Crisis leadership plays a vital role in ensuring that staff feel cared for and safe. Where self-care and stress manage- ment were not adequately emphasized, more stress was reported, regardless of whether the person was in a supervisory position or not. Previous research on job stress and stress management sug- gests that future iterations of the SPFS may include shared-trauma questions related to whether or not respondents were directly affected by the disaster (Aten et al., 2008; Hansel et al., 2011; Powell & Yuma-Guerrero, 2016; Saakvitne, 2002; Tosone, Nuttman-Shwartz, & Stephens, 2012). Because crisis counselors described more stressful situations in the open-ended response area, perhaps a more in-depth series of questions may be useful in identifying compassion-fatigue issues. Last, an item related to the socioeconomic status or annual income of the crisis-counselor staff could be included, as this variable may also have an impact on disaster-job stress, such as was found in a study of 9/11 workers

Table 6 Multiple Regression Predicting Job Satisfaction

Variables B SE � t p

Training usefulness .291 .050 .298 5.774 .000���

Job stress �.338 .100 �.162 �3.363 .001��

Gender .286 .769 .019 .372 .710 Age 1.267 .601 .109 2.106 .036�

Race 1.249 .733 .088 1.706 .089 Full- or part-time .237 .704 .017 .337 .736 Highest education level �.526 .639 �.043 �.823 .411 Supervisory position �1.655 .884 �.097 �1.873 .062

Note. R2 � .165, adjusted R2 � .145. � p � .05. �� p � .01. ��� p � .001.

25DISASTER-CRISIS-COUNSELOR JOB FEEDBACK

(Naturale, 2009). Gender was also not statistically significant in the regression equation, as the study sample included a large majority of women, close to 75%. This may have had implication for the equation model and a limitation for male impact in this study.

The qualitative analysis showed some areas of potential im- provement for the CCP, such as communication at all organiza- tional levels (i.e., top to bottom and bottom to top), training, team-leader support, and stress management aspects. Many of the remarks indicated that enhancements to the earlier stages of the program could make their later work easier. Although some ob- servations from respondents highlighted areas for addressing chal- lenges, they also provided positive program comments. Respon- dents identified that the CCP had helped them to build their skills and enrich their connections to individuals, families, and organizations in their communities, which suggests increases in community resilience that may be protective in the event of future disasters. Also, most important, the comments suggested that respondents wanted to make a difference in their communities, and the CCP was the best avenue to do that.

Based on study results, we offer some key recommendations: (a) Emphasize survivor-engagement strategies during trainings and ensure use of just-in-time training among those who deliver in- terim services; (b) conduct skills-based training earlier in the CCP, such as PFA, SPR, and activities to engage children/youth, such as HATS (Schonfeld & Gurwitch, 2009) or family GOALS interven- tions, taking into account time from the date the disaster occurred, as opposed to the grant cycle; (c) address cultural and safety issues in outreach with communities to be served, and (d) develop a toolkit that includes supervisory management tips from hiring to program close that could include more day-to-day operations to better support job competency, track job stress, compassion fa- tigue, and frustration. In future efforts to improve response rates and reduce the amount of missing data for some question items, SPFS administration could benefit from a mobile technology ap- plication to improve data quality and completion by incorporating reminders and validation checks. During the data-training portion of the CCP, the importance of the SPFS could be further empha- sized to highlight the benefits of completing the survey, especially when the program is coming to an end. In addition, updating survey-administration resources (such as the survey announcement and cover letter) with concrete examples of how feedback from the forms has been used could facilitate program improvements.

References

Aten, J. D., Madson, M. B., Rice, A., & Chamberlain, A. K. (2008). Postdi- saster supervisor strategies for promoting supervisee self-care: Lessons learned from Hurricane Katrina. Training and Education in Professional Psychology, 2, 75–82. http://dx.doi.org/10.1037/1931-3918.2.2.75

Berkowitz, S., Bryant, R., Brymer, M., Hamblen, J., Jacobs, A., Layne, C., . . . Watson, P. (2010). Skills for psychological recovery: Field operations guide. Washington, DC: National Child Traumatic Stress Network and United States National Center for PTSD.

Brymer, M., Jacobs, A., Layne, C., Pynoos, R., Ruzek, J. I., Steinberg, A., . . . Watson, P. (2006). Psychological first aid: Field operations manual (2nd ed.). Washington, DC: National Child Traumatic Stress Network and United States Department of Veterans Affairs, National Center for PTSD.

Everly, G. S., Jr., Lee McCabe, O., Semon, N. L., Thompson, C. B., & Links, J. M. (2014). The development of a model of psychological first aid for non-mental health trained public health personnel: The Johns Hopkins RAPID-PFA. Journal of Public Health Management and Prac- tice, 20, S24–S29. http://dx.doi.org/10.1097/PHH.0000000000000065

Galea, S., Tracy, M., Norris, F., & Coffey, S. F. (2008). Financial and social circumstances and the incidence and course of PTSD in Missis- sippi during the first two years after Hurricane Katrina. Journal of Traumatic Stress, 21, 357–368. http://dx.doi.org/10.1002/jts.20355

Hansel, T. C., Osofsky, H. J., Steinberg, A. M., Brymer, M. J., Landis, R., Riise, K. S., . . . Speier, A. (2011). Louisiana Spirit Specialized Crisis Counseling: Counselor perceptions of training and services. Psycholog- ical Trauma: Theory, Research, Practice, and Policy, 3, 276–282. http://dx.doi.org/10.1037/a0024644

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., . . . Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry: Interpersonal and Biological Processes, 70, 283–315. http:// dx.doi.org/10.1521/psyc.2007.70.4.283

Jacobs, G. A., Gray, B. L., Erickson, S. E., Gonzalez, E. D., & Quevillon, R. P. (2016). Disaster mental health and community-based psychological first aid: Concepts and education/training. Journal of Clinical Psychol- ogy, 72, 1307–1317. http://dx.doi.org/10.1002/jclp.22316

Johnstone, M. (2007). Disaster response and group self-care. Perspectives in Psychiatric Care, 43, 38–40. http://dx.doi.org/10.1111/j.1744-6163 .2007.00104.x

McCabe, O. L., Everly, G. S., Jr., Brown, L. M., Wendelboe, A. M., Abd Hamid, N. H., Tallchief, V. L., & Links, J. M. (2014). Psychological first aid: A consensus-derived, empirically supported, competency-based training model. American Journal of Public Health, 104, 621–628. http://dx.doi.org/10.2105/AJPH.2013.301219

Naturale, A. (2009). Selected professional predictors of posttraumatic and secondary traumatic stress: The long term impact of 9/11/01 in a sample of Manhattan social workers in direct practice. Doctoral dissertation, New York University, New York, NY [Abstract No. 3353023]. Ann Arbor, MI: ProQuest Information & Learning.

Naturale, A. (2015). How do we understand disaster-related vicarious trauma, secondary traumatic stress, and compassion fatigue? In G. Quintangon, & M. R. Evces (Eds.), Vicarious trauma and disaster mental health: Understanding risks and promoting resilience (1st ed., pp. 73–89). New York, NY: Routledge.

Neria, Y., & Shultz, J. M. (2012). Mental health effects of Hurricane Sandy: Characteristics, potential aftermath, and response. JAMA: Jour- nal of the American Medical Association, 308, 2571–2572. http://dx.doi .org/10.1001/jama.2012.110700

Norris, F. H., & Bellamy, N. D. (2009). Evaluation of a national effort to reach Hurricane Katrina survivors and evacuees: The Crisis Counseling Assistance and Training program. Administration and Policy in Mental Health and Mental Health Services Research, 36, 165–175. http://dx.doi .org/10.1007/s10488-009-0217-z

Norris, F. H., Hamblen, J. L., & Rosen, C. S. (2009). Service characteris- tics and counseling outcomes: Lessons from a cross-site evaluation of crisis counseling after Hurricanes Katrina, Rita and Wilma. Administra- tion and Policy in Mental Health and Mental Health Services Research, 36, 176–185. http://dx.doi.org/10.1007/s10488-009-0215-1

North, C. S., & Pfefferbaum, B. (2013). Mental health response to com- munity disasters: A systematic review. JAMA: Journal of the American Medical Association, 310, 507–518. http://dx.doi.org/10.1001/jama .2013.107799

Powell, T., & Yuma-Guerrero, P. (2016). Supporting community health work- ers after a disaster: Findings from a mixed-methods pilot evaluation study of a psychoeducational intervention. Disaster Medicine and Public Health Preparedness, 10, 754–761. http://dx.doi.org/10.1017/dmp.2016.40

26 BELLAMY, WANG, MCGEE, LIU, AND ROBINSON

Quitangon, G., & Evces, M. R. (Eds.). (2015). Vicarious trauma and disaster mental health: Understanding risks and promoting resilience (1st ed.). New York, NY: Routledge.

Reifels, L., Naccarella, L., Blashki, G., & Pirkis, J. (2014). Examining disaster mental health workforce capacity. Psychiatry: Interpersonal and Biological Processes, 77, 199–205. http://dx.doi.org/10.1521/psyc.2014 .77.2.199

Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. § 5121 et seq. (1974). Public Law 93–288, as amended, 2013.

Robinson, M. E. (2016). Behavioral health: A natural nursing fit. Nursing, 46, 61–65. http://dx.doi.org/10.1097/01.NURSE.0000490211.08320.1d

Saakvitne, K. W. (2002). Shared trauma: The therapist’s increased vulner- ability. Psychoanalytic Dialogues, 12, 443–449. http://dx.doi.org/10 .1080/10481881209348678

Schonfeld, D. J., & Gurwitch, R. H. (2009). Addressing disaster mental health needs of children: Practical guidance for pediatric emergency health care providers. Clinical Pediatric Emergency Medicine, 10, 208– 215. http://dx.doi.org/10.1016/j.cpem.2009.06.002

Smith, A. R., Silva, C., Covington, D. W., & Joiner, T. E., Jr. (2014). An assessment of suicide-related knowledge and skills among health pro- fessionals. Health Psychology, 33, 110–119. http://dx.doi.org/10.1037/ a0031062

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Service Provider Feedback Survey. Office of Management and Budget No. 0930-0270. Expiration 09/30/2018. Rockville, MD.

Tosone, C., McTighe, J. P., & Bauwens, J. (2015). Shared traumatic stress among social workers in the aftermath of Hurricane Katrina. British Journal of Social Work, 45, 1313–1329. http://dx.doi.org/10.1093/bjsw/ bct194

Tosone, C., Nuttman-Shwartz, O., & Stephens, T. (2012). Shared trauma: When the professional is personal. Clinical Social Work Journal, 40, 231–239. http://dx.doi.org/10.1007/s10615-012-0395-0

Uekawa, K., Higgins, W. B., Golenbock, S., Mack, A. R., & Bellamy, N. D. (2016). Psychometric properties of disaster event reaction items from the Crisis Counseling Individual/Family Encounter Log. Disaster Medicine and Public Health Preparedness, 10, 822–831. http://dx.doi .org/10.1017/dmp.2016.60

Underwood, M., Milani, J., & Spinazzola, N. (2004). Families GOALs: A training manual. Verona, NJ: Mental Health Association of New Jersey.

United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2016). The dialogue: Stress management and self-care. Retrieved from http://www.samhsa .gov/dtac/disaster-behavioral-health-resources/dialogue

Vernberg, E. M., & Hambrick, E. P. (2013). Helping people cope with disasters. In G. P. Koocher, J. C. Norcross, & B. A. Greene (Eds.), Psychologists’ desk reference (3rd ed., pp. 711–716). New York, NY: Oxford University Press. http://dx.doi.org/10.1093/med:psych/ 9780199845491.003.0137

Vernberg, E. M., Steinberg, A. M., Jacobs, A. K., Brymer, M. J., Watson, P. J., Osofsky, J. D., . . . Ruzek, J. I. (2008). Innovations in Disaster Mental Health: Psychological First Aid. Professional Psychology, Re- search and Practice, 39, 381–388. http://dx.doi.org/10.1037/a0012663

Zunin, L. M. D. (2000). Training manual for mental health and human service workers in major disasters (DHHS Publication No. 90–538). Washington, DC: United States Department of Health and Human Ser- vices.

Received January 27, 2017 Revision received September 13, 2017

Accepted September 23, 2017 �

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